Whether Pulmonary Valve Replacement in Asymptomatic Patients With Moderate or Severe Regurgitation After Tetralogy of Fallot Repair Is Appropriate: A Case‐Control Study

He, Fengpu; Feng, Zhen; Chen, Qiuming; Jiao, Yiwen; Hua, Zhongdong; Zhang, Hao; Yang, Keming; Pang, Kunjing; Lu, Minjie; Ma, Kai; Zhang, Sen; Qı, Lei; Wang, Guanxi; Li, Shoujun

doi:10.1161/jaha.118.010689

Cited by 20 publications

(14 citation statements)

References 29 publications

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“…Although right ventricle size decreases and functional class improves after pulmonary valve replacement, right ventricular normalization does not occur very often and modest amount of patients achieve increased systolic function [2,5,7,13,14,16,[21][22][23][24][25][26]. We failed to observe any significant change in the right ventricle measurements after pulmonary valve replacement, only TAPSE and right ventricular outflow tract gradient increased significantly.…”

Section: Discussionmentioning

confidence: 76%

“…Marked right ventricle enlargement and dysfunction can be present before the onset of symptoms, which explains the discouraging outcomes in some of the symptomatic patients. Hence, early intervention in asymptomatic patients is advocated [4,7]. Assuming that the less severe the ventricular dilatation prior to valve replacement, the more likely the ventricle will remodel, many investigators tried to determine the right ventricle measurements beyond which return to normal size is unlikely [5,[15][16][17].…”

Section: Discussionmentioning

confidence: 99%

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Echocardiographic Follow-Up of Right Ventricular Function After Tetralogy of Fallot Operation

Ayabakan¹,

Tokel²,

Sarısoy³

2020

JICOA

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Aim: Although limited in assessing right ventricular (RV) function, echocardiography is widely used after correction for tetralogy of Fallot (TOF). The change in echocardiographic measurements of RV in asymptomatic patients after TOF repair over a long follow-up time is not explored yet. The variation in simple echocardiographic measurements during follow-up of our TOF patients are presented. The predictive value of those parameters in determining a future pulmonary valve replacement is sought. Method: Asymptomatic patients surviving the first year after correction for simple TOF from February 2007 to December 2019 at Başkent University, Istanbul Hospital are enrolled. Patients are followed annually with echocardiography including: RV area, volume, length, RV outflow tract (RVOT) diameter and gradient, tricuspid annulus diameter, tricuspid lateral annular tissue velocities, tricuspid annular plane systolic excursion, TEI index RV ejection fraction (EF) measurements. The change in the consecutive echocardiographic measurements during follow-up is analysed. Patients are evaluated with a cardiac magnetic resonance (CMR) imaging when deemed necessary and compared with echocardiographic measurements. Results: A total of 66 patients (54.5% males) are operated at age 14.4±9.3 months (78.8% with transannular patch). Twelve patients had pulmonary valve replacement (PVR) operation at an age 10.1±3.1 years. During follow-up of 7.2±4.3 years, tricuspid annulus diameter, RV area, RV inlet length, RV volume, RV volume index significantly increased (p=0.001 for all), whereas RV inlet length index, TEI and TEI z score decreased (p<0.0001 for all). When means are compared, tricuspid annulus (28.8mm vs 25.0mm; p=0.013), RV volume (72.2ml vs 52.2ml; p=0.042), RV inlet length index (77.9mm/m2 vs 60.2mm/m2 ; p=0.013), RVOT diameter (28.7 vs 23.0; p=0.007) are increased. RV EF is decreased (51.3% vs 60.5%; p=0.011) in those requiring PVR. Those with higher RV area index, RV volume index, tricuspid annulus diameter and tricuspid annular z score in their first echocardiography after the TOF repair, are more likely to have a PVR operation later on (p<0.05 for all). RV volume index ≥39ml/m2 predicts a PVR within 7 years with 100% sensitivity and 74% specificity. Tricuspid annular z score less than -0.43 seems to eliminate the possibility of having a PVR within 7 years with a sensitivity of 44% and specificity of 100%. Conclusion: Observing the sequential change in echocardiographic parameters like RV volume index, RV area index, tricuspid annulus z score is reliable in determining right ventricular function and can limit the costly CMR applications. Cut off values of RV volume index >39ml/m2 and tricuspid annulus z score ≥ - 0.43 after the initial TOF repair may determine patients with higher possibility of having early PVR and indicate a closer follow-up.

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Section: Discussionmentioning

confidence: 76%

Section: Discussionmentioning

confidence: 99%

Echocardiographic Follow-Up of Right Ventricular Function After Tetralogy of Fallot Operation

Ayabakan¹,

Tokel²,

Sarısoy³

2020

JICOA

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“…A propensity-matched cohort from the INDICATOR registry showed no advantage in adverse effects in the group undergoing PVR, although with the limitations of retrospective matching [ 6 ]. In a recent small non-controlled trial, PVR was associated with fewer adverse events in an asymptomatic population with moderate PV regurgitation [ 7 ]. The question of long-term benefits, or harms, with PVR in rToF and the timing, early versus delayed, is still open to debate.…”

Section: Introductionmentioning

confidence: 99%

Age over 35 years is associated with increased mortality after pulmonary valve replacement in repaired tetralogy of Fallot: results from the UK National Congenital Heart Disease Audit database

Dorobantu

Sharabiani

Taliotis

et al. 2020

European Journal of Cardio-Thoracic Surgery

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OBJECTIVES Many adults with repaired tetralogy of Fallot will require a pulmonary valve replacement (PVR), but there is no consensus on the best timing. In this study, we aim to evaluate the impact of age at PVR on outcomes. METHODS This is a national multicentre retrospective study including all patients >15 years of age with repaired tetralogy of Fallot who underwent their first PVR between 2000 and 2013. The optimal age cut-off was identified using Cox regression and classification and regression tree analysis. RESULTS A total of 707 patients were included, median age 26 (15–72) years. The mortality rate at 10 years after PVR was 4.2%, and the second PVR rate of 6.8%. Age at PVR of 35 years was identified as the optimal cut-off in relation to late mortality. Patients above 35 years of age had a 5.6 fold risk of death at 10 years compared with those with PVR under 35 years (10.4% vs 1.3%, P < 0.001), more concomitant tricuspid valve repair/replacement (15.1% vs 5.7%, P < 0.001) and surgical arrhythmia treatment (18.4% vs 5.9%, P < 0.001). In those under 50 years, there was an 8.7 fold risk of late death compared with the general population, higher for those with PVR after 35 than those with PVR below 35 years (hazard ratio 9.9 vs 7.4). CONCLUSIONS Patients above 35 years of age with repaired tetralogy of Fallot have significantly worse mortality after PVR, compared with younger patients and a higher burden of mortality relative to the general population. This suggests that there are still cases where the timing of initial PVR is not optimal, warranting a re-evaluation of criteria for intervention.

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“…Longstanding PR results in right ventricular (RV) dysfunction, prolongation of QRS duration, supraventricular and ventricular arrhythmias, and reduced life expectancy. [ 1 2 3 4 5 6 7 8 9 10 11 12 13 ] Therefore, symptomatic chronic PR is an indication for pulmonary valve replacement (PVR). However, studies have shown that even after PVR, there is no significant improvement in the uncorrected RV ejection fraction (UnRVEF) and the corrected RVEF also improves only to the extent of preoperative UnRVEF.…”

Section: Introductionmentioning

confidence: 99%

Concomitant pulmonary valve replacement with intracardiac repair for adult tetralogy of fallot

et al. 2021

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Objectives : Adult patients undergoing tetralogy of Fallot (TOF) repair have a higher risk of mortality compared to pediatric patients. Pulmonary regurgitation (PR) further predisposes these patients to heart failure, arrhythmias, and sudden death. Pulmonary valve replacement (PVR) may improve the symptoms in these patients but, fails to reverse the other deleterious effects. Aim of our study was to evaluate the effect of concomitant PVR with TOF repair on right ventricular (RV) parameters, cardiopulmonary exercise capacity, and bioprosthetic valve durability at mid-term. Materials and Methods: Between January 2013 and August 2018, 37 adolescents and adults with TOF who had hypoplastic pulmonary annulus underwent concomitant TOF repair with PVR at our institute. We retrospectively collected the data from the hospital records including follow-up. Results : Mean age of the patients was 18.48 ± 7.53 years. Bioprosthetic valve size ranged from 19 mm to 25 mm. There was no early or late mortality. No patient had developed significant perioperative complications. At a mean follow-up of 53.3 ± 16.4 months, there was no significant change in mean QRS duration, RV function, RV end-systolic and end-diastolic dimensions, RV myocardial performance index, and functional status (including NYHA class and 6-min walk test) compared to at-discharge values. Four patients developed prosthetic valve degeneration with mild PR and without significant increase in gradient. Conclusion : Concomitant PVR with TOF repair in adult provides excellent mid-term outcome, with a minimal rate of pulmonary valve degeneration. It not only eases the early postoperative course but also preserves the RV function as well as functional status at mid-term.

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Whether Pulmonary Valve Replacement in Asymptomatic Patients With Moderate or Severe Regurgitation After Tetralogy of Fallot Repair Is Appropriate: A Case‐Control Study

Cited by 20 publications

References 29 publications

Echocardiographic Follow-Up of Right Ventricular Function After Tetralogy of Fallot Operation

Echocardiographic Follow-Up of Right Ventricular Function After Tetralogy of Fallot Operation

Age over 35 years is associated with increased mortality after pulmonary valve replacement in repaired tetralogy of Fallot: results from the UK National Congenital Heart Disease Audit database

Concomitant pulmonary valve replacement with intracardiac repair for adult tetralogy of fallot

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